A diligently prepared medical summary report helps convey the past and present medical condition of the patient which the patient himself will not be able to communicate accurately.
It can be done in a format that is easily understandable.
Factors that help in creating a good medical summary report:
- Dispatch and Response Summary: The dispatch and response summary provides explicit details of where the unit was dispatched for and on what priority. Included in this report is a short description of the response itself.
- Scene summary: The scene summary provides a brief regarding the status at the scene and what the scene looked like when the dispatch crew arrived at the scene
- HPI/Physical exam: This provides information regarding the initial exam that was performed on the client. The initial exam allows for the patient’s baseline to be established
- Interventions: Interventions include the activities that were performed on the patient, like if vital signs were assessed, IV was initiated, medications that were administered etc.
- Status Change: Mention the change in the patient’s condition. There are instances wherein the patient might have undergone significant change. If so, the same needs to be re-documented for the physical exam, status and intervention change
- Safety summary: This details how the patient was transferred from the scene to the hospital. It also gives details about the safety measures that were performed like safety straps and also information about the patient’s position while transfer
- Disposition: It details the transport from the scene to the hospital or receiving facility. Information regarding what happened outside the facility and where the patient was left after reaching the facility is mentioned there.
Any medical summary preparer has the responsibility of providing accurate information, and the same cannot be done if the report is not prepared correctly by the discharge centre.
Hence ensuring that the above-mentioned points have been highlighted correctly will help in the creation of a successful medical summary report.